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Services That Require Pre-certification


The following services require benefit pre-certification prior to the service being rendered. Written guidelines for most of these services are referenced below.


Procedures requiring pre-certification

Advanced Imaging Studies, see the NIA website at



All stem-cell transplants require pre-certification



Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry


Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder 


Bariatric Surgery


Bio-Engineered Skin and Soft Tissue Substitutes


Blepharoplasty and Repair of Blepharoptosis


Bone (Mineral) Density Studies


Brachytherapy, Noncoronary


Breast Pumps 


Bronchial Thermoplasty


Cardiac-Related Procedures


Carrier Testing for Genetic Diseases


Catheter Ablation as Treatment for Atrial Fibrillation


Charged-Particle (Proton or Helium Ion) Radiation Therapy


Chiropractic Services


Clinical Trials


Cognitive Rehabilitation Therapy (cognitive rehabilitation for patients with traumatic brain injury)


Complementary and Alternative Medicine (CAM)


Glucose Monitoring System


Cosmetic surgery or surgery that may possibly be considered cosmetic. HMSA plans do not cover cosmetic surgery primarily intended to improve a patient's appearance without restoring or materially improving a physical function, nor surgery prescribed for psychological or psychiatric purposes.


However, cosmetic surgeries that meet HMSA's guidelines (see Cosmetic and Reconstructive Surgery and Services) and that are appropriately documented are covered.


Examples of services that may be considered cosmetic are Reduction Mammaplasty for Breast-Related Symptoms and Blepharoplasty and Repair of Blepharoptosis.


Also see Panniculectomy/Abdominoplasty.


For a list of CPT procedure codes that may be considered cosmetic, see Cosmetic Procedures - Claim Documentation Requirements.


To request pre-certification of cosmetic surgery, contact the Pre-certification Unit.


Drugs Requiring Pre-certification

Injectables and Infused Drugs

Other FDA approved drugs. Please refer to FDA-Approved Drugs Requiring Pre-certification


Dietetic Treatment of Eating Disorders


Durable Medical Equipment, Prosthetics and Orthotics


Durable Medical Equipment, Prosthetics and Orthotics - Small Group & Individual Plans, Fed 87


Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)


Gamma-knife surgery,see Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy


Gender Identity Services


Genetic Risk Assessment/Counseling - based on HMSA genetic testing policies for members who are being considered for genetic testing and are at high risk for the following conditions: breast cancer (BRCA), ovarian cancer (BRCA), familial adenomatous polyps (FAP), lynch syndrome (hereditary nonpolyposis colorectal cancer), attenuated familial adenomatous polyps (AFAP), MYH associated polyps (MAP).


Genetic Testing for Hereditary Breast and/or Ovarian Cancer


Genetic Testing for Lynch Syndrome/Colorectal Cancer and Polyposis Syndromes


Genetic Testing for Non-Cancerous Inheritable Diseases


Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies


Growth Hormone Therapy


Habilitative Services


High Frequency Chest Wall Oscillation Devices


Home INR Monitoring


Hospital admissions, The Federal Employee Program (FEP, enrollment codes 104, 105, 111 and 112) require pre-certification of hospital admissions and home hospice care. Pre-certification is not required for maternity admissions unless they exceed two days for vaginal deliveries or four days for cesarean section, or when FEP is secondary to Medicare. (See Federal Employee Program (FEP))


Hyperbaric Oxygen Pressurization (HBO)


Immune Globulin Therapy


Incontinence Supplies


Insulin Pumps - External


Intensity Modulated Radiation Therapy (IMRT)


Islet Transplant


In Vitro Fertilization includes guidelines for coverage. Hawaii providers who are contracted with HMSA bill for In Vitro services based on an all inclusive case rate. If services are rendered by a provider outside of the state of Hawaii or who does not participate with HMSA, medical records must be submitted with the claim. See In Vitro Procedures Requiring Documentation If Not Pre-certified


IV therapy. The following home IV therapies require pre-certification prior to the initiation of the therapy:


Knee Orthoses for Osteoarthritis


Kyphoplasty and Vertebroplasty


Laser Therapy for Plaque Psoriasis


Mental Health or Substance Abuse Residential Care Facility Services Outside the State of Hawaii


Naturopathic Services


Negative Pressure Wound Therapy (NPWT)


Nerve Fiber Density Testing


Occupational therapy. For PPO, HMO, EUTF, HSTA Plans (See Occupational Therapy - PPO, HMO, EUTF, HSTA Plans ) and for Federal Plan 087 (See Occupational Therapy - Federal Plan 87 )


Off-Label Drug Use


Organ transplants
Except kidney and cornea and clinical trials for certain organ transplants. Detailed information is available in specific transplant policies:


Orthodontic Treatment of Orofacial Anomalies


Oscillatory Device for Bronchial Drainage (The Vest)


Oxygen and Oxygen Equipment (for members 13 years of age and older).




Physical therapy. For PPO, HMO, EUTF, HSTA Plans (See Physical Therapy - PPO, HMO, EUTF, HSTA Plans )and for Federal Plan 087 (See Physical Therapy - Federal Plan 87 )


Place of treatment exceptions
When a physician feels a procedure should be performed in a treatment setting other than where HMSA normally deems appropriate, pre-certification approval must be given by HMSA. (See Place of Treatment - Office and Place of Treatment - Outpatient )


Polysomnography - Sleep Studies


Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea


Post-acute and Residential Treatment Facility Stays


Post-acute, Residential Treatment Facility and Community Care Foster Family Home Care


Posterior Tibial Nerve Stimulation


Precertification Requirements - Medicare Advantage Plans


Preimplantation Genetic Diagnosis (PGD)


Pulmonary Rehabilitation


Pulse Oximeter for Children


Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors


Radiology Guidelines for Advanced Imaging Studies


Reduction Mammaplasty for Breast-Related Symptoms


Repetitive Transcranial Magnetic Stimulation for Treatment Refractory Depression


Specialty Drugs Requiring Precertification


Speech Therapy Services/Rehabilitation


Spinal Cord Stimulators for Pain Management


Spinal Interventional Pain Management and Lumbar Spine Surgery


Stereotactic Radiosurgery and Fractionated Stereotactic Radiotherapy


Subcutaneous Implantable Cardioverter Defibrillator (ICD) System


Surgeries, therapies or procedures employing new technology or representing a new application of existing technology.
(See Benefit Information)




Transcatheter Aortic-Valve Implantation for Aortic Stenosis


Transcatheter Closure of Patent Foramen Ovale for Stroke Prevention


Transcatheter Pulmonary Valve Implantation


Transcutaneous Electrical Nerve Stimulation (TENS)


Transplant Evaluations


Treatment of Varicose Veins



Criteria Used in Precertification Decisions

Evidence-based, scientifically established medical appropriateness criteria are used to make pre-certification decisions. Clinical criteria are reviewed annually by the HMSA Utilization Management Committee and are provided to all practitioners. Practitioners also may obtain criteria used for Medical Management decisions by writing to the Pre-certification Unit.



MM: December 2011





First Published:03/16/2007
Latest Revision:12/26/2017
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